The Role of Values and the Practice of Values Base Medicine

Question 1

What are the current challenges in most healthcare systems around the world

Answer 1

In most countries, healthcare expenditure is rising irrespective of the healthcare system structure

Problematic if wages dont increase at the same rate

Question 2

What are the causes of increased expenditure

Answer 2

People living longer with more chronic diseases
Fast pace of technological development

Adding more money only leads to increased demand

Question 3

What is the difference between quality and value in healthcare
What are the 2 problems with these definitions

Answer 3

Quality (ideally all 3 should be met)

• effectiveness
• safety
• positivity

Value

• health outcomes achieved per dollar spent
• people have different values

Question 4

What is the difference between prioritisation and rationing

Answer 4

Prioritisation

• effectiveness of different services compared
• assess evidence
• can result in rationing of services

Rationing

• Can occur by itself
• normally no extensive research or evaluation of services before shut downs
• can be the effect of prioritisation

Question 5

What are the 2 types of rationing

What do they both result in

Answer 5

Explicit

• waiting lists
• denial/delays of access to treatments

Implicit

• can include understaffing in hospitals
• GP prescription behaviours

Both prioritisation and rationing => some patients losing out on what is considered the best quality care for them

Question 6

What are the 5 ways to make priority setting decisions

Describe them

Answer 6

Clinical need
-all that is clinically necessary and medically possible should be financed

Capacity to benefit
-those who will gain the most from treatment will be prioritised

Clinical effectiveness
-only interventions that achieve outcomes should be financed

Cost effectiveness
-costs must be justified in relation to the expected benefits

Patient characteristics
-disease severity and lifestyle choices considered

Question 7

Why are the pros and cons of priority setting based on clinical need

Answer 7

Pros

• Patient at heart of decision making
• focus on clinical autonomy and patient dr relationship

Cons

• hard to define
• not everything that is medically possible is necassary
• expenditure control is hard

Question 8

What are the pros and cons of priority setting based on capacity to benefit

Answer 8

Pros
-Cost effective use of resources due to clinical effectiveness in patient groups

Cons
-not fair to all groups

Question 9

What are the pros and cons of priority setting based on clinical effectiveness

Answer 9

Pros
-EBM

Cons
-thresholds for clinical effectiveness hard to determine

Question 10

What are the pros and cons of priority setting based on cost effectiveness

Answer 10

Pros

• EB, value approach => comparisons between diseases and interventions
• present and future societal needs recognised

Cons

• determining thresholds for cost effectiveness is hard
• individual patients may lose out

Question 11

What are the pros and cons of priority setting based on patient characteristics

Answer 11

Pros
-allows for consideration of societal preferences

Cons

• risk of discrimination against groups
• link between lifestyle and disease can’t be proven

Question 12

Describe prioritisation and rationing in the UK on

• a national level
• local level

Answer 12

NICE addresses the postcode lottery problem by making treatment recommendations to the NHS

Priority setting at a local level is not clear

• lack of research into what is effective
• can’t access evidence for what works easily

Question 13

Describe the link between money and quality of care

Answer 13

Generally, more money => more quality

However, for this to work, you must use the money effectively to get the most out of it

Question 14

What is justice

What are the 2 approaches to justice

Answer 14

Fair and appropriate distribution of services between patients without discrimination

Utilitarian approach

• allocate to maximise benefit across whole society
• some will lose out

Egalitarian approach
-everyone is equal, everyone should have an equal opportunity to get healthcare regardless of value for money

Question 15

What is procedural justice and the 3 steps included in the ‘accountability for reasonableness’

Answer 15

Ensures that even if people disagree with the results, they feel comfortable that the right processes have been followed

1. Process is public and understandable to those involved in decision
2. Reasons for outcome are relevant to problem
3. Procedures that allow stakeholders and public to challenge decisions exist

Question 16

What is the role of societal values in healthcare

Answer 16

Understand the values of patients and society in which you are making decisions

Question 17

What is the framework of social values for healthcare

• 2 values
• 3 aspects of each value

Answer 17

Process values

• Accountability (now, you are accountable to your employer and patients)
• Participation of patients in their own treatment
• Transparency in decision making

Content values

• Cost effectiveness (how to identify groups which have lost out as a result of their treatment not being cost effective)
• equity in treatment
• clinical effectiveness

Question 18

What are the 8 underlying social values that NICE uses

Describe them

Answer 18

Evidence
-intervention not reccommeded is there is no/not enough evidence to make a clear decision

Value for money
-consider relative costs and benefits

Fairness
-consider distribution of resources fairly to the whole of society, not just evidence or relative cost benefits alone

Provide explanation
-justify why some treatments are/are not cost effective

Limits of autonomy
-denying treatment is ok as clinical and patient autonomy is not greater than societal need

Consultation but not consensus
-consults all stakeholder groups, takes all evidence into consideration and makes a decision

Non discriminatory
-can recommend an intervention to certain groups but must justify why

Reduce inequality
-active consideration of reducing health inequalities